Subtotal hysterectomy and myomectomy – Vaginally




Vaginal subtotal (or supracervical) hysterectomy and vaginal myomectomy are elegant procedures rarely carried out by the average gynaecologist. Both techniques, however, are easily learned, and in view of the proven advantages of vaginal surgery over abdominal or laparoscopic approaches, they are worthy of a wider application. Subtotal hysterectomy may be preferred to excision of the entire uterus in certain circumstances, and may be carried out vaginally. Vaginal myomectomy allows for a more thorough myomectomy and stronger uterine repair than a laparoscopic procedure, as well as avoiding abdominal wounds. It may represent the optimal approach where fibroids are favourably sited. We first set out the case for subtotal hysterectomy and then describe the development of vaginal subtotal hysterectomy and vaginal myomectomy. We discuss the evidence supporting their use and indications, and then describe techniques for both vaginal procedures.


Development and justification of subtotal hysterectomy compared with total hysterectomy


Subtotal hysterectomy (STH), otherwise known as supracervical hysterectomy, is an operation that removes only the body of the uterus and conserves the cervix. Total hysterectomy involves excision of the entire uterus, including the cervix. The first hysterectomy was subtotal and carried out abdominally in 1863 by Charles Clay of Manchester. STH was the hysterectomy of choice until after 1929, when Edward Richardson of Johns Hopkins Hospital, Baltimore, was the first to complete a successful total abdominal hysterectomy (TAH). The lack of cervical cancer screening at the time, the development of antibiotics and the increasing availability of blood transfusion resulted in TAH almost entirely replacing STH in the 1950s. STH was thereafter reserved for women with gross elongation of the cervix, for caesarean hysterectomy, or where the pouch of Douglas was obliterated by rectovaginal endometriosis or dense adhesions. An emergency STH may still be safer in the above situations, although with careful dissection it is usually possible to excise the cervix.


In Bonney’s Gynaecological Surgery (1986), it was stated that STH ‘…is only mentioned to say that there is no indication for its presence in a modern surgical text.’ STH is an unpopular operation in the UK (accounting for 9% of hysterectomies ), as shown by a survey of views and practice among British gynaecologists. Of female gynaecologists, 78% would prefer to have a TAH themselves rather than a subtotal procedure. Perhaps because STH is a technically simpler operation than TAH, many gynaecologists feel that it reflects poorly on their surgical skill.


A survey of attitudes and practice relating to STH compared with TAH that was mailed to 1647 gynaecologists in Washington, Maryland, and Virginia, USA, showed that 63% of these gynaecologists did not counsel women about the relative advantages and disadvantages of these two operations. Only 19% always offered women a choice between the procedures; 61% rarely or never did.


Removing the cervix as a preventative measure against the development of cervical cancer was used for many years as the main argument for total hysterectomy; however, with the introduction of effective cervical screening programmes, it is now unjustified. In rural and poverty-stricken areas of the developing world today, no effective cervical screening exists, and over 90% of women may not have had a Papanicolaou smear. The risk of cervical stump carcinoma in women with a previously normal smear is 0.3%, similar to the risk of vaginal carcinoma after hysterectomy for a benign condition, and also comparable to the risk of ureteric injury at TAH (0.2–1%) and standard vaginal hysterectomy (0.1%).


Interest in STH increased when Kurt Semm introduced the laparoscopic technique in 1991. The ‘Classic Abdominal Semm Hysterectomy (CASH),’ as with subsequent incarnations of the laparoscopic supracervical hysterectomy, avoided the two pitfalls of laparoscopic total hysterectomy: uterine vessel haemorrhage and ureteric injury.


Semm’s CASH cored out the entire transformation zone and endocervical canal to reduce the risk of cervical cancer and to ablate menstruation in 90% of women, similar to today’s classic intrafascial supracervical hysterectomy. The earlier method of ablating the cervical canal with electrosurgical coagulation had been shown to reduce the incidence of cervical stump carcinoma from 0.4% to 0.1%. It is true that treatment of subsequent cervical cancer is more difficult after STH, but there is no evidence that prognosis is affected.


Further justification for STH was stimulated by the perception that less sexual, bladder and bowel dysfunction results from laparoscopic supracervical hysterectomy compared with total hysterectomy. However, these conclusions were based on a number of poorly controlled retrospective studies lacking in preoperative assessment of sexual function, and have not been confirmed by subsequent randomised-controlled trials. We review the available evidence for STH below and for ease of reference we compare with TAH in Tables 1 and 2 .



Table 1

Advantages of subtotal hysterectomy compared with total hysterectomy. a








  • Faster



  • Less intraoperative blood loss



  • Decreased incidence of vault haematoma



  • Decreased risk of postoperative pyrexia



  • Less risk of ureteric injury


a Although there are circumstances in which subtotal hysterectomy is preferred for the above surgical reasons, the cervix is commonly conserved at hysterectomy as a result of patient preference.



Table 2

Limitations of subtotal hysterectomy.










Contraindicated if significant cervical abnormality is present
Smears continue to be required
If a patient desires hormone replacement therapy, the oestrogen must be opposed with a progestogen as endometrium may remain, thus increasing her risk of breast cancer.
Light menstruation may continue. Although most endometrium may be excised or destroyed at subtotal hysterectomy, amenorrhoea cannot be guaranteed


Surgical time, immediate complications and hospital stay


A 2006 Cochrane review of three randomised-controlled trials compared STH with TAH in 733 women. It showed that STH is a faster operation and that intraoperative blood loss is significantly less, although no evidence of a difference in the odds of transfusion was found. Vault haematoma seems to be less likely after STH, and the reviewers concluded the same for fever (OR 0.43, 0.25–0.75). This lower rate of postoperative pyrexia (6% v 19% in one randomised trial of 279 women ) largely accounts for the overall lower complication rate of STH compared with TAH. No evidence was found of a difference in the rates of other complications, recovery from surgery or readmission rates.


Most trials do not include a sufficient number of participants to detect differences in rare complications. There is certainly less dissection in the region of the uterine isthmus in STH, and ureteric injury is therefore less likely. Urinary tract injuries are the most common cause of litigation after hysterectomy and are usually indefensible. Also, as dissection does not proceed beyond ligation of uterine vessels, less bladder mobilisation is necessary and so one may suppose the risk of bladder trauma is also reduced.


Bladder and bowel function


Despite popular perception, the Cochrane reviewers concluded that there is no evidence of a difference in the rates of incontinence, constipation or measures of sexual function. In one of these trials, a greater proportion of women reported frequent urinary incontinence after STH compared with TAH (OR 2.1, 1.01–4.29), although this was due to a larger reduction of the number of women with stress and urinary incontinence in the TAH group. This difference was not confirmed by the other two trials that measured stress and urge incontinence and urinary frequency.


Sexual function


Reports published in the early 1980s suggesting sexual benefits of preserving the cervix at hysterectomy drew the public’s attention. Subsequent prospective studies failed to support those findings. A randomised double-blind multi-centre trial from the UK found measures of urinary, bowel and sexual function was similar in both STH and TAH groups 1 year after surgery, and in fact sexual function did not change after surgery. A study comparing the effects of conventional vaginal hysterectomy, STH and TAH on sexual well-being over 6 months concluded that sexual pleasure improved similarly after all three operations.


Various aspects of the average woman’s postoperative sex life have been reported as no different after STH compared with TAH. Both procedures do not affect sex life up to 1 year after surgery, but both clearly reduce dyspareunia (with P = 0.009 significance). This has been shown in a Danish multi-centre randomised trial of 319 women whose responses to a variety of questions were analysed on an intention-to-treat basis. The investigators concluded that a shift toward STH seems unwarranted. Rather than the extent of the surgery, postoperative satisfaction with sex life was influenced by preoperative satisfaction (OR 32, 95% CI 10–125), a good relationship with one’s partner (OR 50, 95% CI 9–354), physical well-being (OR 0.30, 95% CI 0.09–0.88) and the use of hormone replacement therapy (OR 0.23, 95% CI 0.06–0.78). Finally, a separate retrospective questionnaire study with a 41% response rate also published in 2004 found no difference in sexual function between 126 women who underwent STH, TAH or standard vaginal hysterectomy.


Pelvic organ prolapse


As less damage is caused to the parametrium (cardinal and uterosacral ligaments) and paracolpium, one might expect less prolapse after STH than after TAH. However, this is not the case.


As early as 1933, Read and Bell, in a follow-up review of 1739 women who had undergone STH and 603 who had undergone TAH, could find only four cases of vault prolapse, all occurring after the subtotal operation. Gwillim clearly stated in 1950 that prolapse of the vault is seen as often after subtotal as after total hysterectomy. He, like many others, did not believe that the cervix ‘acted as a keystone of an arch for vault support’.


Almost 40 years ago, Krige reported that five times as many cases of prolapse as total excision occur after STH. A similar pattern was found in a large retrospective study of 711 women after surgery: 6.2% v 2.2% had prolapse after STH and TAH, respectively. Whether STH is associated with a higher incidence of prolapse is thus debatable, and will be settled by follow-up of existing randomised studies. Whatever these conclude, it could be that preservation of the cervix may permit simultaneous procedures that offer better prophylactic support to the pelvic floor (see below).


It therefore seems certain that cervical retention does not help to prevent prolapse, and does not contribute to a better sex life.


Menstruation


Ongoing cyclical vaginal bleeding 1 year after surgery is more likely (OR 11.3, 4.1–31.2) after STH compared with TAH owing to residual endometrial tissue.


Mental health and quality of life


A Scandinavian group studied psychological factors up to 3 years after surgery, and suggested a statistically significant difference in favour of STH. In particular, nervousness, irritability and depression seem to decrease during the follow-up period significantly in the STH but not in the TAH group. However, this was not a randomised study. A recent and scientifically more rigorous study came to different conclusions, namely that all women showed an improvement in psychological symptoms following either type of hysterectomy.




The vaginal approach to hysterectomy


Of the 38,000 hysterectomies carried out annually by the National Health Service in England, higher proportion are by the abdominal compared with the vaginal approach in a 4:1 ratio. However, since the first reported elective vaginal hysterectomy by Conrad Langenbeck from Göttingen in 1813, it is now well established that (primarily by avoiding the abdominal incision) vaginal hysterectomy is the faster operation, with fewer complications, shorter recovery time and less cost. Other countries, Such as Finland, have been swifter to grasp these advantages, where the proportion of hysterectomies carried out abdominally fell from 58% to 34% from 1996 to 2006, to a reversed ratio of almost 1:2.


A Cochrane Review of 34 randomized trials of abdominal TAH, laparoscopic, and vaginal hysterectomies concluded that vaginal hysterectomy has the best outcome and should be carried out in preference to TAH where possible (and where vaginal hysterectomy is not possible, laparoscopic hysterectomy may confer advantages in avoiding the need for laparotomy). The American College of Obstetrics and Gynecology Committee (2009–2010) has endorsed this advice.


In the absence of extrauterine pathology, no overall benefit has been found from total laparascopic hysterectomy compared with vaginal hysterectomy. The operating time is longer, equipment more costly, and the procedure carries a higher complication rate.


Evidence shows that vaginal hysterectomy is frequently the best operation, and also feasible for women who are frequently denied the procedure in favour of abdominal or laparoscopic hysterectomy. The absence of prolapse, presence of a moderately enlarged uterus, and the desire for oophorectomy are not contraindications to vaginal hysterectomy. Indeed, in the absence of other pelvic disease, laparoscopy-assisted vaginal hysterectomy has been shown to be an expensive and time-consuming alternative to standard vaginal hysterectomy.


It would therefore also seem logical to approach the uterus vaginally when the cervix is to be conserved. The counterintuitive procedure of vaginal STH is described below.




The vaginal approach to hysterectomy


Of the 38,000 hysterectomies carried out annually by the National Health Service in England, higher proportion are by the abdominal compared with the vaginal approach in a 4:1 ratio. However, since the first reported elective vaginal hysterectomy by Conrad Langenbeck from Göttingen in 1813, it is now well established that (primarily by avoiding the abdominal incision) vaginal hysterectomy is the faster operation, with fewer complications, shorter recovery time and less cost. Other countries, Such as Finland, have been swifter to grasp these advantages, where the proportion of hysterectomies carried out abdominally fell from 58% to 34% from 1996 to 2006, to a reversed ratio of almost 1:2.


A Cochrane Review of 34 randomized trials of abdominal TAH, laparoscopic, and vaginal hysterectomies concluded that vaginal hysterectomy has the best outcome and should be carried out in preference to TAH where possible (and where vaginal hysterectomy is not possible, laparoscopic hysterectomy may confer advantages in avoiding the need for laparotomy). The American College of Obstetrics and Gynecology Committee (2009–2010) has endorsed this advice.


In the absence of extrauterine pathology, no overall benefit has been found from total laparascopic hysterectomy compared with vaginal hysterectomy. The operating time is longer, equipment more costly, and the procedure carries a higher complication rate.


Evidence shows that vaginal hysterectomy is frequently the best operation, and also feasible for women who are frequently denied the procedure in favour of abdominal or laparoscopic hysterectomy. The absence of prolapse, presence of a moderately enlarged uterus, and the desire for oophorectomy are not contraindications to vaginal hysterectomy. Indeed, in the absence of other pelvic disease, laparoscopy-assisted vaginal hysterectomy has been shown to be an expensive and time-consuming alternative to standard vaginal hysterectomy.


It would therefore also seem logical to approach the uterus vaginally when the cervix is to be conserved. The counterintuitive procedure of vaginal STH is described below.




Vaginal subtotal hysterectomy


In 1994, the technique of vaginal hysterectomy described in 1906 by Döderlein and Kronig was modified to permit STH purely by the vaginal route. Döderlein and Kronig had previously described vaginal STH in their original textbook, but by the 1990s the operation had been forgotten. This surgery is less extensive than vaginal total hysterectomy and, of course, being a purely vaginal procedure, it does not require an abdominal incision or laparoscopic expertise.


At first sight, it would seem impossible to carry out a STH vaginally. The method involves making a semicircular vaginal incision anterior to the cervix, opening the uterovesical fold and delivering the uterine body into the vagina through this anterior colpotomy. The pedicles are then ligated and divided in a caudal direction, similar in order to that of the TAH. Whereas, with the classic Döderlein–Kronig vaginal hysterectomy, the dissection is continued until the whole uterus has been excised, STH is achieved by ending dissection at the level of the cervix and amputating the body of the uterus, the pouch of Douglas remaining intact. This technique has several advantages as well as limitations compared with the procedure described by Noble Sproat Heaney, which remains the standard method of vaginal hysterectomy for most gynaecologists ( Table 3 ).



Table 3

Comparison of vaginal hysterectomy techniques.


































Heaney (Total) Döderlein–Kronig (Subtotal) Advantage or disadvantage of Döderlein–Kronig technique
Incision Circumferential colpotomy Anterior colpotomy No oozing from posterior vaginal incision
Direction Cephalad Caudal Better visualisation of pedicles and easier to comprehend and teach
Access More restricted Better Procedure is easier as it is essentially carried out in the lower vagina and introitus
Uterine size Up to 20 weeks Up to 12–14 weeks Not suitable for large uterus
Subtotal hysterectomy Not feasible Feasible More options for the surgeon and the patient


As always, good patient selection is paramount. The cornerstones of successful and safe vaginal hysterectomy are: (1) good uterine mobility; (2) adequate vaginal access; and (3) experienced assistants. The importance of this last point cannot be over-emphasised, as highlighted by John Studd, Consultant Gynaecologist in London: ‘a vaginal hysterectomy is an operation of assistants’ (personal communication), a view which is as true today as it was then.


An important consideration for vaginal STH, which is not so relevant to the vaginal total hysterectomy, is that the uterus should not be overly large as it must be delivered into the vagina through an anterior colpotomy. Realistically, this means that the uterine size should not be greater than that of a 12–14 week pregnancy. Although some of the techniques used to debulk a uterus at total hysterectomy can be applied, it is more difficult when the Döderlein–Kronig approach is used. During debulking, vascular pedicles are yet to be ligated and greater blood loss is to be expected, until after torsion of the uterus through the anterior colpotomy when haemorrhage is surprisingly slight. It is true that laparoscopic assistance may be used to prepare an otherwise unfavourable case for vaginal STH (e,g. prior adhesiolysis) ; however, such cases could also be managed by a purely laparoscopic operation. The prior use of GnRH analogues to facilitate delivery of a subsequently smaller uterus through a colpotomy is another option in the presence of uterine enlargement, in the same way as they permit vaginal surgery more generally where fibroids are present.


Vaginal STH, if combined with sacrospinous (cervico) colpopexy, may be a more acceptable operation to a young woman with uterine prolapse requiring hysterectomy for another reason, provided she has completed her family. The indication for hysterectomy should not be prolapse, as it is currently thought that hysterectomy per se has little effect on prolapse (and that better alternative surgical treatments are available for this indication). Sacrospinous fixation with preservation of the uterus, which has been described previously, may be just as effective as sacrospinous cervicocolpopexy after STH, for example.


Technique of subtotal vaginal hysterectomy


Our practice is to carry out hysterectomy under general anaesthesia, but regional anaesthesia may also be used. All patients are given adequate thromboprophylaxis (heparin and antiembolic stockings) and prophylactic antibiotics. Positioning the patient is important and ideally should be done by the surgeon. Rather than standard lithotomy, we recommend a position in which the patient’s legs are held relatively straight toward the ceiling, out of the way of the two assistants, with good hip flexion and abduction. To achieve this, we use the poles designed by gynaecologist Káre Lakinger from Arendal in Norway. Routine bladder catheterisation is not done provided the bladder is relatively empty: we prefer to catheterise at the end of the procedure to confirm that the bladder has not been injured.


Manipulation of the cervix is achieved with two tenacula positioned at 6 and 12 o’clock. The anterior vaginal fornix is infiltrated with 20 ml of 1% lignocaine containing adrenaline 1: 200,000. An anterior colpotomy at the cervicovaginal junction is carried out between 9 and 3 o’clock, and the bladder is reflected with sharp and blunt dissection. The peritoneal fold, typically identified as a transverse white line, is opened, and a vaginal retractor is placed under the bladder to provide access to the anterior uterine wall and to protect the bladder from injury.


The remainder of the procedure, as mentioned previously, is based on the Döderlein–Kronig vaginal hysterectomy ( Table 4 ). The uterus needs to be delivered through the anterior colpotomy. Although clamps can be used, we prefer to use a strong nylon or Prolene suture to ‘walk up the anterior wall of the uterus.’ At the start, a deep bite is taken into the anterior surface of the uterus as high as feasible. Downward traction of the suture brings the uterus lower, allowing a second bite higher up. By continuing with these steps, the fundus is eventually reached and the uterus can be delivered into the vagina ( Figs. 1 and 2 ). Should this prove impossible because of the size of the uterus, there is the option of first excising one or more anterior, fundal fibroids, or both, to sufficiently debulk the uterus and so allowing its delivery into the vagina (as in vaginal myomectomy, see later).



Table 4

Steps in a vaginal subtotal hysterectomy using the Döderlein–Kronig technique.

































1 Empty bladder if full
2 Infiltrate cervix with local anaesthetic and vasoconstrictor
3 Make anterior semi-circumferential colpotomy
4 Deliver uterus through incision
5 Clamp, divide and ligate ovarian pedicles
6 Clamp, divide and ligate uterine pedicles
7 Amputate uterine body
8 Core out the cervical endometrium
9 Suture cervical stump
10 Close colpotomy incision



Fig. 1


Walking up the anterior wall of the uterus; the next suture is placed into the uterus above the previous suture until the fundus is reached.



Fig. 2


Traction is then applied on the fundus to deliver the uterus through the anterior colpotomy into the vagina.


Once through the colpotomy, the vascular pedicles are visualised, clamped, cut and doubly ligated in the same order as with abdominal hysterectomy. The ovarian vessels are taken either lateral or medial to the ovaries, depending on the need for oophorectomy; if direct clamp application on the infundibulopelvic ligament is difficult, this may be carried out after the uterus has been removed by applying medial traction to the ovary. The uterine vessels are then taken just above the cervix.


In the case of STH, the excision stops here and the body of the uterus is amputated from the cervix. A cone-shaped incision is made in the cervical stump to remove endometrial tissue from the endocervix; if this is judged to be insufficient, either the cervical stump incision can be made deeper, or the area can be electrocoagulated to destroy residual endometrium. Coring out the top of the cervix also facilitates closure of the incision for which we use a continuous locking suture.


After the cervical stump is returned to its normal position, the peritoneum and anterior colpotomy are closed with interrupted sutures. The bladder is emptied but we do not routinely insert a vaginal pack. After surgery, the patient is encouraged to mobilise early.


Vaginal myomectomy


As with hysterectomy, myomectomy has traditionally been carried out by laparotomy. Over the past 25 years, laparoscopic and hysteroscopic myomectomy have become accepted procedures for selected cases. Laparotomy carries a greater risk of haemorrhage and sepsis, blood transfusion, and more extensive postoperative adhesion formation, whereas the endoscopic procedures have all the advantages associated with minimal access surgery (e.g. less postoperative pain, faster recovery, earlier discharge from hospital and better cosmetic result). Unfortunately, laparoscopic and hysteroscopic myomectomy have limitations and are reserved for women with a few relatively small fibroids that are positioned favourably for endoscopic surgery ( Table 5 ). In addition, these routes of surgery are not risk-free, and expensive equipment and endoscopic skill are not always available, indeed unavailable in 80% of the developing world.



Table 5

Limitations of traditional routes of myomectomy.




































Route Limitations
Abdominal myomectomy Requires laparotomy
Haemorrhage
Sepsis
Postoperative adhesions
Laparoscopic myomectomy Technically difficult with intramural fibroids
Limited to relatively small and few fibroids
Long operative time
Haemorrhage
Weak uterine scar
Hysteroscopic myomectomy Only suitable for submucosal fibroids
Limited to relatively small and few fibroids
Uterine perforation
Fluid overload

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Nov 9, 2017 | Posted by in OBSTETRICS | Comments Off on Subtotal hysterectomy and myomectomy – Vaginally

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